September 18, 2024

expert reaction to network meta-analysis of medicines for migraine

A study published in The BMJ reviews various drug interventions for the acute management of migraines. 

Dr. Eloisa Rubio-Beltran, Migraine Trust Research Associate and Headache Group, Wolfson Sensory, Pain and Regeneration Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, said:

“This work was highly needed, it will not only have an impact in future studies but also, in migraine treatment guidelines and policy-making. Future clinical trials should evaluate the efficacy of novel drugs not only in comparison to placebo, but also, in comparison with current treatments, to assess their efficacy in similar populations. Moreover, the involvement of people with lived experience of migraine in the design of this study should set the precedent in the field, and be the norm in future studies.

“As the study highlights, due to their high efficacy and low cost, triptans should be the first-line treatment option for the acute treatment of migraine. And, while that is already the case in several countries, with sumatriptan being part of the List of Essential Medicines of the World Health Organization, not all patients have access to them. These results should inform treatment guidelines and support the inclusion of the best performing triptans into the List of Essential Medicines, to optimize treatment, allowing patients to access more efficacious options.

“It is worth noting that gepants and ditans were developed because not all patients benefit from triptans, either due to lack of efficacy, the presence of side effects, or because they are contraindicated due to their effect on blood vessels. As such, these novel drugs were not developed to substitute triptans, but to expand the treatment armamentarium. Nonetheless, this study highlights the need for further research on the pathophysiology of migraine, which will allow the discovery of novel targets, and thus, novel treatments options that will benefit all patient populations.”

Prof Peter Goadsby, Director of NIHR Clinical Research Facility & Professor of Neurology, King’s College London, said:

“The press release describes the mechanism of action of migraine drugs. Migraine medicines, including triptans, have complex actions with the most widely held view being their mode of action involves nerve pathways important in migraine.

“This is good quality research with the main take home message being triptans are under-utilised for migraine being supported by the data here that is in keeping with other existing evidence.  

“As highlighted by the authours, there are some limitations of the work. First, there is a lot of heterogeneity of the trials they look at which can mean there is “low or very low” confidence in some comparisons between drugs. Secondly, the work is based on average treatment effects, so this is still unable to offer insights at an individual patient level. Finally, clinical trial results do not integrate efficacy, side effects and consistency, which together impact the patient outcomes in the medium and long term.”

‘Comparative effects of drug interventions for the acute management of migraine episodes in adults: systematic review and network meta-analysis’ by William K Karlsson et al. was published in The BMJ at 23:30 UK time on Wednesday 18^th September. 

DOI: http://dx.doi.org/10.1136/bmj-2024-080107  

Declared interests

Dr. Eloisa Rubio-Beltran: Junior Editorial Board Member of The Journal of Headache and Pain, Junior representative of the International Headache Society. Research support from Migraine Trust, Eli Lilly and Company, CoLucid Pharmaceuticals, Inc., Amgen, Novartis and Kallyope Inc. Travel support from CoLucid Pharmaceuticals, Inc., Allergan and Novartis.

Prof Peter Goadsby:  PJG reports, over the last 36 months, grant from Kallyope, and personal fees from Aeon Biopharma, Abbvie, Aurene, CoolTech LLC, Dr Reddy’s, Eli-Lilly and Company, Linpharma, Lundbeck, Pfizer, PureTech Health LLC, Satsuma, Shiratronics, Teva Pharmaceuticals, Tremeau, and Vial